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SAN.JOAVCOUNTY ENVIRONMENTAL HEALTWPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5 6 iR 16 (5 s i A-r I c ��� (o 3 �5 tcc&C? <br /> OWNER/OPERATOR <br /> AVT AA `� CHECK If BILLING ADDRESS <br /> FACILITY NAME/ + <br /> 71, <br /> SITE ADDRESS __ CC, Lt � 19—Y CLu,9 S�j C v--r C'�l L4 S I Y <br /> tree[ umber Direction I Street Name Cit Zi Code <br /> HOME Or MAILING ADDRESS (If Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 EXT. APN# LAND USE APPLICATION# <br /> (zo$ 93-a — 13 Q'7 <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR <br /> �,y CHECK If BILLING ADDRESS <br /> BUSINESS NAME PHONE# EXT. <br /> HOME or MAILING ADDRESS FAX# <br /> CITY SAM��,Q STATE C tk ZIP 0!4S(P <br /> BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUiN <br /> COUNTY Ordinance Codes,Standards, STATE and FEDERAL. laws. <br /> APPLICANT'S SIGNATURE: /�.�� DATE: <br /> PROPER1Y/BUSINESS OWNER❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Corti J C q Z✓` <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: ��S E i CI ( `Ir PAY <br /> COMMENTS: L <br /> uld <br /> SEP U 7 Z004VIRONNIMT HEALTH <br /> SAN,IOAO mC0 I I IST/SERVICE <br /> HF_. tj DEPARTMENT <br /> ACCEPTED BY: ®LI VE_�t 9�.A EMPLOYEE#: 03 u DATE: <br /> ASSIGNED TO: EMPLOYEE#: rL J DATE: �( I <br /> Date Service Completed (if already Completed): SERVICE CODE: P 1 E:z3f)a` <br /> Fee Amount: 3 Amount Paid Payment Date (�, I 1 k 0 <br /> Payment Type ✓� S Invoice# Check#LAD(A %D Received By: <br /> REVDISED 110 17/2003 D Q% '36 <br /> �b V p SR FORM(Golden Rod) <br />